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Acute Appendicitis:Current Issues and Controversies
Malen M. Gellido, MD. MHPEd
April 6, 2013
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Outline
1. Anatomy, Pathophysiology, Epidemiology
1. Diagnosis Imaging modalities
2. Treatment Medical vs. Surgical
Type of surgery: open or laparoscopic
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AppendixDa Vinci (1492) Vesalius (1543)
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Anatomy and Physiology
The base is consistently foundat the confluence of the taeniaat the base of the cecum
The tip is retrocecal in 65%
Average length is 9cm
An immunologic organ that
actively participates in thesecretion of immunoglobulins,particularly immunoglobulin A
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Reginald Heber Fitz (1886)
Coined the term appendicitis
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Pathophysiology of Acute Appendicitis
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Incidence of Appendicitis
The most common of the intraabdominal inflammatorydisorders, occurring in both genders and in all agegroups.
The incidence is approximately 233/100,000population and is highest in the 10 to 19 year-old agegroup
It is also higher among men (male to female ratio of1.4:1), who have a lifetime incidence of 8.6 percentcompared to 6.7 percent for women
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Appendicitis in Children
The most common indication for emergentabdominal surgery in childhood.
Diagnosed in up to 8% of children evaluated urgently
for abdominal pain. Perforation correlates strongly with duration of
symptoms:
Neonates 83%
Young children (12 years) 10 to 20 %
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Appendicitis during Pregnancy
The most common general surgical problemencountered during pregnancy
Acute appendicitis is suspected in 1/600 to 1/1000pregnancies and confirmed in 1/800 to 1/1500pregnancies
The incidence is slightly higher in the secondtrimester than in the first and third trimesters orpostpartum
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Standard management of
Acute Appendicitis
Schwartz, Principles of Surgery, 9th
Ed
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Current Issues
1. The use of imaging modalities
2. Medical versus surgical treatment
3. Open versus laparoscopic surgery
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Current Issues
What is the role of imaging technologies in the
diagnosis of acute appendicitis?
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Current Issues
What is the role of imaging technologies in the
diagnosis of acute appendicitis?
Used mainly for equivocal cases
Children
Pregnant patients
Elderly patients
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Ultrasound
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Noncompressible tubular structure in right lower quadrant
Wall thickness of the appendix greater than 2 mm
Overall diameter greater than 6 mm
Free fluid in the right lower quadrant
Thickening of the mesentery
Localized tenderness with graded compression
Presence of a calcified appendicolith
Ultrasound findings that support the diaganosis of Appendicitis
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CT Scan
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The appendix is considered abnormal on CT scan
when:
It is distended or thickened and greater than
approximately 5 to 7 mm in diameter.
The wall of the inflamed appendix is
circumferentially thickened and may appear as ahalo or target.
CT findings of periappendiceal inflammation suggest
appendicitis; these include:
periappendiceal abscess
fluid collections
edema
phlegmon
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MRI
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Current Issues
Medical management Surgical ManagementVS.
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Medical Treatment
Amoxicillin plus clavulanic acid versus
appendicectomy for treatment of acute
uncomplicated appendicitis: an open-label, non-
inferiority, randomised controlled trial.Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B,
Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco
Lancet. 2011;377(9777):1573.
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Medical Treatment
Postoperative peritonitis was significantly more frequent in
patients treated with amoxicillin plus clavulanic acid
compared with appendectomy (8 versus 2%).
Fourteen patients (12%) treated with antibiotics underwent
an appendectomy within 30 days of treatment.
An additional 30 patients underwent an appendectomy within
the year following antibiotic therapy, 26 of whom had
confirmed acute appendicitis.
Vons et al, Lancet 2011
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Medical Treatment
Antibiotic therapy versus appendectomy for
acute appendicitis: a meta-analysis.
Varadhan KK, Humes DJ, Neal KR, Lobo DN
World J Surg. 2010;34(2):199.
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Medical Treatment
Among the 350 patients treated with antibiotics alone, 112
(32 percent) failed initial medical therapy and were treatedwith an appendectomy.
In the 238 patients who responded to medical therapy and
did not undergo surgery during the acute episode, symptoms
recurred in 38 (16 percent) within one year and underwentappendectomy.
Histologic findings were available for 35 patients and included
phlegmon in 25, perforation in 9, and gangrene in 1.
Overall, 58 percent of the initial cohort treated withantibiotics remained asymptomatic at one year of follow-up.
Varadhan et al, World J Surg. 2010
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Surgical Treatment
Appendectomy is the gold standard treatment
of acute appendicitis.
The negative appendectomy rate should be
within 10%.
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Current Issues
Open surgery Laparoscopic surgeryVS.
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1894
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The first reported case
of appendectomy was
performed by Claudius
Amyand in 1735.
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Semm performed the first
successful laparoscopic
appendectomy in 1982.
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Open vs. Laparoscopic Surgery
Laparoscopic versus open surgery forsuspected appendicitis.
Sauerland S, Jaschinski T, Neugebauer E
Cochrane Database Syst Rev. 2010
A meta-analysis of 56 randomized trials and 11studies compared the outcomes of approximately
6000 adults and children with suspected acuteappendicitis undergoing either laparoscopicappendectomy or conventional open laparotomy
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Laparoscopic appendectomy
Advantages
A lower rate of wound
infections (odds ratio [OR]
0.43, 95% CI 0.34-0.54)
Less pain on postoperativeday 1 by the VAS pain score (8
mm, CI 5-11 mm)
Shorter duration of hospital
stay (1.1 days, CI 0.7-1.5 days)
Shorter duration for return of
bowel function
Disadvantages
A higher rate of an intra-
abdominal abscess (OR 1.77,
CI 1.14-2.76)
A longer operative time (10minutes, CI 6-15 minutes)
Higher operative and in-
hospital costs
Sauerland et al, Cochrane Database. 2010
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NOTES
Natural orifice
translumenal
endoscopic surgery
(NOTES) Transgastric
Transrectal
Transvaginal
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NOTES - Transvaginal
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Summary
Schwartz, Principles of Surgery, 9th Ed
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Thank you
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Treatment: Medical or Surgical?
1735 Claudius Amyand performed the veryfirst appendectomy
1839 Bright and Addison, described signs and symptoms
of appendicitis but surgery as treatment was not mentioned
1870 advent of anesthesia and asepsis and antiseptic techniques
allowed safer and more tolerable abdominal surgery
But Removal of the appendix was still not widely accepted
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Appendectomy Incision: What to use?